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Industry Services Division County L <br /> ;-. <br /> 1400 E Washington Ave G r <br /> 0 P.O.Box 71 b2 <br /> Isi p Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,W153707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forts for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.040 m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 9j, A(ev,hJ - <br /> Property Owner's Mailing Address Property Location <br /> 171 6 �6 Tax�D �9 13 <br /> GovL Lot <br /> City,S r.eLy,, Zip C[oodey Phone Number V4 %, Section _ <br /> /'r t°N (/V i, S�U�J T N. R le E oW <br /> II.Type of Building(check all that apply) Lot <br /> I or 2 Family Dwelling-Number of Bedrooms /' Subdivision Name <br /> Blocklr QU ( V1kJ1 VV <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CS(vl Number ❑Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, �New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Ointter <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> CYNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Hording Tank ❑Other Dispersal Component(explain) Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow( d) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units L o 4 <br /> New Tanks Existing Tanks v ` <br /> V <br /> V V N <br /> w`U in �, cn ii t7 ii <br /> Scptic or Holding Tan /TT0 Dosing Chamber v <br /> VII.Responsibility Statement-k the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P1u cr's Name(Print) Plumber's/Si9aturc MP/MPRS Ntttuber Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (5 tf f Ao,/7-rt t A �Je r 5'1b9 <br /> VIII.Coun /De artment Use Onl <br /> Approved ❑Disapproved Permit Fee C� Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �'o l dow aucoon+`/ a►d S-(-�-k red u i�e wte,t-,+5 I Inn, LE� F V[E <br /> Attach to coniplete ptaos for the s)vmm and submit to the Cowtty only on paper not less than 8112 111 lne*0 in size <br /> APR 2 3 M.J U <br /> Burnett county <br /> SBD-6398(R.09114) Land Services Department <br />